Youth Component

RI-CHY-2007-06-29

Working Toward Wellness

Youth Assent Form

Today we’d like to talk to you about what it’s like to be a young person these days. We are studying the daily lives and experiences of families and young people. Your mother said it is OK for me to talk with you today, as long as it is OK with you.

What we are studying

We are interested in finding out how young people your age think and feel about different things, such as how you feel about yourself, your family, and friends, and your life at school and home. I am going to ask you some questions about these things. There are no right or wrong answers to my questions. I am interested in your ideas and opinions. If you do not feel like answering a question, that’s okay, you can just skip it and go onto the next one. If you decide you don’t want to do any more, please tell me and we can stop at any time. It is OK to tell me that you want to stop.

The whole interview will take about 45 minutes and we can take a break if you need to. When we are done with this interview, you will receive a $20 gift card.

Additionally, by giving us permission to interview you, you will also be giving us permission to get information from the state or United Behavioral Health about your use of Medicaid or medical services, such as visits to see the doctor, or taking medications that the doctor prescribed to you.

Protecting your information

Your name will not be kept in the same file with your answers, so no one will know how you answered these questions. Instead, files with your answers will have a special identification number on them. We keep your name in a separate location so it cannot be linked to your answers.

We will do everything we can to keep others from learning about your participation in the research. We have a Confidentiality Certificate from the U.S. government that adds special protection for the research information that identifies you. It says we do not have to identify you, even under a court order or subpoena. You should know, however, that we may tell someone if harm to you, harm to others, or child abuse becomes a concern (this report would not be based on any information that comes out of any of your saliva samples). Also, the federal agency that pays for this study may see your information in an audit, but it too will protect your privacy. This Certificate does not mean the government approves or disapproves of our project.

If you have questions, ask us!

You can ask any questions that you have about this study. If you have a question later that you didn’t think of now, you can ask us later. Signing here means that you have read this paper or someone read it to you and that you are willing to be in this study. If you don’t want to be in this study, don’t sign. Remember, being in this study is up to you, and no one will be mad at you if you don’t sign this, or even if you change your mind later.

If you have questions at any time during the study, please call Francisca Azocar or Kathy Sweet at United Behavior Health toll-free at (800) 207-0084. You can also call David Butler or Pamela Morris at MDRC using the toll-free number (800) 221-3165.

When I sign my name here I am saying that I agree to be interviewed for this study. I am also saying that I understand what I am supposed to do and that I may stop the interview at any time.

Print your name __________________________________________________________

Sign your name ___________________________________ Date __________________

Signature of Interviewer ____________________________ Date __________________

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